Risk factors for refracture of the forearm in children treated with elastic stable intramedullary nailing

Subsequent Forearm Fractures Following Initial Surgical Fixation

INTRODUCTION

Forearm fractures are a common pediatric injury. Currently, there is no consensus on treatment for fractures that recur following initial surgical fixation. The objective of this study was to investigate the subsequent fracture rate and patterns and describe the treatment of these forearm fractures.

METHODS

We retrospectively identified patients who underwent surgical treatment for an initial forearm fracture at our institution between 2011 and 2019. Patients were included if they sustained a diaphyseal or metadiaphyseal forearm fracture that was initially treated surgically with a plate and screw construct (plate) or elastic stable intramedullary nail (ESIN), and if they subsequently sustained another fracture that was treated at our institution.

RESULTS

A total of 349 forearm fractures were treated surgically with ESIN or a plate fixation. Of these, 24 sustained another fracture, yielding a subsequent fracture rate of 10.9% for the plate cohort and 5.1% for the ESIN cohort ( P =0.056). The majority of plate refractures (90%) occurred at the proximal or distal plate edge, while 79% of the fractures treated previously with ESINs occurred at the initial fracture site ( P <0.001). Ninety percent of plate refractures required revision surgery, with 50% underwent plate removal and conversion to ESIN, and 40% underwent revision plating. Within the ESIN cohort, 64% were treated nonsurgically, 21% underwent revision ESINs, and 14% underwent revision plating. Tourniquet time for revision surgeries were shorter for the ESIN cohort (46 vs. 92 min; P =0.012). In both cohorts, all revision surgeries had no complications and healed with evidence of radiographic union. However, 9 patients (37.5%) underwent implant removal (3 plates and 6 ESINs) after subsequent fracture healing.

CONCLUSIONS

This is the first study to characterize subsequent forearm fractures following both ESIN and plate fixation and to describe and compare treatment options. Consistent with the literature, refractures following surgical fixation of pediatric forearm fractures may occur at a rate ranging from 5% to 11%. ESINs are both less invasive at the time of initial surgery and can often be treated nonoperatively if there is a subsequent fracture, while plate refractures are more likely to be treated with a second surgery and have a longer average surgery time.

LEVEL OF EVIDENCE

Level IV-retrospective case series.

Prognostic factors for postoperative complications after K-wire fixation for paediatric forearm fractures: a multivariate analysis

Although osteosynthesis using K-wires is a commonly performed procedure, the outcome is not always preferable. We aimed to identify the prognostic factors for postoperative complications in paediatric patients with both-bone forearm fractures. We reviewed 160 paediatric patients who underwent K-wire osteosynthesis for either distal or diaphyseal forearm fractures. We defined the occurrence rate of postoperative complications as the primary outcome and performed a multivariate logistic regression analysis. Variables such as age, sex, mechanism of injury, presence of an open fracture, ulnar or radial fracture and the associated procedure, the K-wire tip procedure and operation time, the duration from injury to operation and operation to implant removal, and duration of casting were included into the model as possible prognostic factors. The mean follow-up period was 51.2 weeks. The total number of complications was 43 (26.2%). Results of the logistic regression analysis indicated that a shorter duration from surgery to K-wire removal caused a significantly higher rate of postoperative complications [odds ratio (OR), 0.99; 95% confidence interval (CI), 0.97-1.0]. The subgroup analyses revealed that intramedullary K-wire fixation for radial fractures (OR, 1.07 × 10-5; 95% CI, 5.46 × 10-10 to 0.211) and a longer casting duration (OR, 0.84; 95% CI, 0.72-0.99) resulted in fewer postoperative infections. An exposed wire tip in the ulna contributed to more postoperative displacement (OR, 6.87; 95% CI, 1.76-26.9). To decrease the risk of postoperative complications, surgeons should bury the wire tip beneath the skin to facilitate a longer duration of K-wire placement.

Implant removal associated complications after ESIN osteosynthesis in pediatric fractures

PURPOSE

ESIN (elastic stable intramedullary nailing) is considered the gold standard for various pediatric fractures. The aim of this study was to analyze the incidence and type of complications during or after TEN (titanium elastic nail) removal.

METHODS

A retrospective data analysis was performed. Metal removal associated complications and preoperative extraosseous length/outlet angle of TENs as possible causes of complications were assessed.

RESULTS

The complication rate in 384 TEN removals was 3.1% (n = 12). One major complication (rupture of M. extensor pollicis brevis) was documented. One refracture at the forearm occurred, however, remodeling prior TEN removal was completed. Ten minor complications were temporary or without irreversible restrictions (3 infections, 5 scaring/granuloma, 2 temporary paraesthesia). In 38 cases (16 forearms, 10 femora, 9 humeri, 3 lower legs), intra-operative fluoroscopy had to be used to locate the implants. In patients with forearm fractures, extraosseous implant length was relatively shorter than in cases without fluoroscopy (p = 0.01), but outlet angle of TENs was not significantly different in these two groups (28.5° vs 25.6°). In patients with femur fractures, extraosseous implant length and outlet angle were tendentially shorter, respectively, lower, but this did not reach statistical significance.

CONCLUSION

Removal of TENs after ESIN is a safe procedure with a low complication rate. Technically inaccurate TEN implantation makes removal more difficult and complicated. To prevent an untimely removal and patient discomfort, nail ends must be exactly positioned and cut. Intraoperative complications may be minimized with removal of TENs before signs of overgrowth.

EVIDENCE

Level III, retrospective.

Management of pediatric forearm fractures: what is the best therapeutic choice? A narrative review of the literature

PURPOSE

This narrative review intends to summarize the most important and relevant data on diagnosis and treatment of pediatric forearm fractures and to describe the characteristics and advantage of each therapeutic option.

METHODS

We conducted a literature research considering peer-reviewed papers (mainly clinical trials or scientific reviews) using the string "forearm fracture AND epidemiology" or "forearm fracture AND diagnosis or " forearm fracture AND treatment" or "forearm fracture AND casting" or "forearm fracture AND surgery". Studies were identified by searching electronic databases (MEDLINE and PubMed) till April 2020 and reference lists of retrieved articles. Only English-language articles were included in the review.

RESULTS

Conservative management with cast immobilization is a safe and successful treatment option in pediatric forearm fractures. Surgical indication is recommended when an acceptable reduction cannot be obtained with closed reduction and casting. Surgical treatment options are intramedullary nail, plating and hybrid fixation.

CONCLUSIONS

There is not a unique consensus about fracture management and treatment. Further studies are necessary to create univocal guidelines about optimal treatment, considering new techniques and available technologies.

Extra-articular proximal femur fractures in children and adolescents treated by elastic stable intramedullary nailing

PURPOSE

Extra-articular proximal femur fractures (EPFF) remain challenging for their intrinsic instability. The aim of this study is to evaluate the results of elastic stable intramedullary nailing (ESIN) of extra-articular proximal femur fractures in children and adolescents.

METHODS

A retrospective monocentric study of children treated by ESIN for EPFF between 2012 and 2018 was conducted. We included all patients sustaining a fracture within 10% of the femur length below the lesser trochanter. Studied data were age, sex, femur length, fracture distance below the lesser trochanter, number of days of hospitalization, time to nail removal, and complications. Beaty's criteria and the titanium elastic nailing (TEN) outcome measure scale were used to evaluate radiologic outcome and assess clinical recovery, respectively.

RESULTS

A total of 24 cases were reviewed (18 males, 6 females). Mean age was 8.23 years (range 5-13). Mean duration of hospitalization was 3.7 days (range 2-12). Mean time to nail removal was 28 weeks (range 12-53). Malalignment was observed in five patients, but in all cases, angulation did not exceed 10°. No limb length discrepancy was observed. Twenty out of 24 patients had excellent Beaty's radiological and TEN clinical outcome scores. No poor results were observed.

CONCLUSIONS

The results of our study show that good outcomes following surgical treatment by ESIN should be expected in children younger than 14 years of age with displaced EPFF. Excellent radiological and clinical outcomes were observed in 83.7% of the cases, with a low rate of complications and short hospital stay.